Achonu: States Must Improve Primary Healthcare Delivery

The Country Director, The ONE Campaign, Stanley Achonu, in this interview, sheds light on the Basic Health Care Provision Fund and the role of the states in improving primary healthcare service delivery across the country. Ugo Aliogo presents the excerpt:

Tell us about the Basic Health Care Provision Fund (BHCPF) and why it is critical to Nigeria’s healthcare delivery?

When Nigeria passed the National Health Act in 2014, it not only formed a comprehensive overhaul of the entire governance framework for health, but also changed all historical and existing legislations and modernised the country’s health system laws. That Act passed by the National Assembly and signed at the twilight of President Jonathan’s administration in 2014 was also supposed to be drawn off by all the states to modernise their existing laws. 

The National Health Act made provisions for the Basic Health Care Provision Fund (BHCPF) as a federal government intervention fund for primary health care. It is an intervention fund because, according to the constitution of the federal republic of Nigeria, local and state governments are responsible for the management, administration, and day-to-day operations of primary health care. Therefore, anything the federal government does about primary healthcare is an intervention to assist the states in providing high-quality healthcare at the basic level.

The Act stipulates that one percent of the federal government’s Consolidated Revenue Fund (CRF) will be dedicated to the Basic Health Care Provision Fund (BHCPF). It also outlines the administrative and accountability frameworks to ensure that the fund is properly managed by the three gateways and adequately utilized by primary healthcare facilities.

It is vital to note that fund disbursement did not begin immediately after the bill was passed.   It took many years of advocacy by health advocates and stakeholders such as the ONE Campaign, National Advocates for Health, and others before the federal government approved the first allocation in 2018. They have disbursed a couple of times since then.

In terms of why it is critical for healthcare delivery in Nigeria, the Basic Health Care Provision Fund (BHCPF) caters directly to the smooth running of primary health facilities across the country. In Nigeria, primary healthcare centers serve as the foundation for healthcare delivery. I call it the foundation because everyone who becomes ill, particularly the poor and vulnerable, generally goes to the primary healthcare centers first. So, if you do not have functional, quality primary healthcare, your entire health system is in disarray because you have gotten the foundation wrong.

Primary healthcare is also essential because it is the first line of defence in preventing disease outbreaks. As the first point of contact, it is easier for primary health centers to notice disease trends and quickly alert national agencies such as the Centers for Disease Control and all relevant federal and state health ministries. However, if the primary healthcare system is not functional, the first line of defence in detecting any disease outbreak has already failed. This is why primary healthcare facilities are highly critical.

You recently launched a report that looks at the implementation of the BHCPF by the states. What do you hope to achieve with the release of the report?

Our organisation and other stakeholders campaigned for the Basic Health Care Provision Fund to be operational. We had celebrities such as Waje, Kate Henshaw, and others who worked hard on advocacy efforts to get this fund established. So, with the creation of the fund, we thought the federal government had done their part, and we needed to start thinking about how to drive accountability in terms of how and what the fund is now being used for to ensure that we are getting the expected result and that the required improvement is being delivered.

The essence of the ‘State of Primary Healthcare Service Delivery in Nigeria’ report is to push for transparency and accountability in the utilisation of the BHCPF. This is not to say that the federal government does not have its accountability mechanism. But we believe it is also important to have an outside push supporting the federal government’s effort because they are already committing a significant amount of money from their revenue to state responsibility. In order to force the states to take action, we thought that a comprehensive review of how they have performed using existing data would be timely and essential. That was what drove us to do this report, and I urge everyone to download the digital version of the report.

It has been four years since the fund was added in 2018; based on the findings in the ‘State of Primary Healthcare Service Delivery in Nigeria’ report, what is the implementation status of the fund?

As you rightly mentioned, it’s been four years since the Basic Health Care Provision Fund was implemented. The first disbursements were made in 2019, and a total of 31 states have been onboarded into the programme. About 7,000 health facilities across these 31 states are receiving decentralised facility funding. From the report’s findings, the challenge of poor health facilities affects all 36 states and the Federal Capital Territory. The ranking of the states does not imply that any of them is perfect; instead, it demonstrates the best performer. Community members across all the states have all sorts of complaints about the nature of health service delivery, which is generally not very pleasant. As many as 13 States fared badly in the implementation of the Basic Health Care Provision Fund. At the heart of Nigeria’s primary health care systems are challenges like weak governance system and operational inefficiencies.

In your estimation, what are the major challenges confronting the implementation of the BHCPF to improve primary healthcare?

The first challenge is inconsistent disbursement from the Federal Ministry of Health. Let me quickly add that fluctuations in federal government revenue impact the funds available for disbursement. We saw that during the COVID period when the federal government had to revise its budget. There is also the issue of delay in transferring the funding. A few gateways already have a trigger that initiates transfers and guarantees they are delivered within a particular number of days. However, this is a problem for some other getaways. 

The second challenge is getting the states to comply with the legal requirements that set up the fund in terms of the ability to access it. In essence, the challenge plaguing the Universal Basic Education in terms of counterpart funding also affects the Basic Health Care Provision Fund. Many states are unable to make their own counterpart funding available as required.

The last issue I would like to address is the fund’s poor data and financial management, which complicates accountability since the necessary data to make certain decisions is not collected or stored in a structured manner.

Let’s talk about the role of state governments since they are closer to primary health facilities. How involved are the states in all of these, and what do you think state governments need to do in order to improve the implementation of BHCPF?

One key challenge with the states is the legal environment around which healthcare delivery is being implemented. The legal framework requires strengthening and modernization. The ‘State of Primary Healthcare Service Delivery in Nigeria’ report made copious findings about where the states are on this issue. Some states have laws, but the policies that support those laws do not exist. Some have policies but no laws to back them up.

Additionally, states need to prioritise health funding; I don’t think there is any challenge that any arm of government in Nigeria is facing that does not include funding. The Basic Health Care Provision Fund is complementary and should not be the sole source of financing primary healthcare delivery in the states. It is the responsibility of the state to fund primary healthcare and deliver quality primary healthcare services to the poor and vulnerable in Nigeria. However, we found that many states do not make provisions for their counterpart funding, resulting in inadequate health funding. Even those who make commitments in the budget speeches hardly release the fund. 

Another issue identified by the report is states’ inability to adequately staff existing health facilities, while many primary healthcare facilities struggle with staffing and regular training for their staff. This trend needs to change. States must recognize that they have not delivered complete quality health service until patients can access qualified personnel who cater to their needs. 

What more does the federal government need to do to spur the states to action, especially in policy and oversight?

First of all, let me start with the National Assembly. The National Assembly, through the constituency projects, seems to act at times as though it is assisting in addressing some of these challenges by indiscriminately citing and building primary healthcare centers without appropriate regard to what constitutes a primary healthcare center.

It is important to state that buildings and modern equipment alone do not constitute a functional primary health center. So, when National Assembly members build a primary healthcare center as part of their constituency projects without consulting with the National Primary Health Care Development Agency (NPHCDA), which is responsible for federal government intervention in this, or in consultation with the state, what you end up with is a modern building with new equipment without personnel to man because staffing is the responsibility of state and local governments. 

On the other hand, the federal government must be more consistent in releasing these funds to primary health facilities. To show their commitment, they can go further to guarantee that should the consolidated revenue fund fall short of the previous year’s funding due to economic realities, they can draw more funds from additional sources to bring it to the previous year’s standard.  This is comparable to the World Bank team’s proposal that instead of having one percent funding from the federal government’s Consolidated Revenue Fund, the government should target one percent of the federation’s Consolidated Revenue. The federal government has also pledged that the newly implemented sugar tax would go toward health. We must think strategically about channeling a part of that towards primary healthcare.

There are also issues around staffing and management of the fund. When you look at the Universal Basic Education (UBE) fund, thousands of people are handling and disbursing this money; in the case of the BHCPF, there are just thirteen staff administering this fund across 36 states under an entity like the NPHCDA.  It means that the capacity to deliver, monitor and track is limited already. We must consider ways to support the administration of this fund to ensure that it is utilised appropriately. We should also start thinking about reward mechanisms for states delivering the desired outcomes. And this is a conversation for stakeholders to think about.

Currently, the federal government contributes only one per cent of the Consolidated Revenue Fund (CRF) to the BHCPF. How significant is this in addressing the country’s decay in primary health facilities?

Of course, the funding is not in any way sufficient, considering the magnitude of the challenge we are discussing. But we must also recognise that the federal government is simply intervening; as such, we can only appeal for more funding, not impose. 

In terms of how much the federal government has already invested in this fund. In 2019, around 27 billion naira was disbursed, while in 2021, approximately 28 billion naira was disbursed. So since its inception, the federal government has provided about 56 billion naira as an intervention fund through the BHCPF. There is also donor funding, where the World Bank has committed about 4 billion naira, and the Bill and Melinda Gates Foundation has contributed over half a billion naira to this fund. One of the positive actions the federal government has taken is to designate the BHCPF as a statutory transfer, which is an indication of their level of commitment. The main issue here is getting the states to the same level of commitment so that regardless of how much revenue they generate, they contribute their counterpart funds for the delivery of basic healthcare services. That might be a way to sustain the funding for the state.

Nigeria’s health systems require billions and billions of naira to get us to where we need to be. Even committing 15 per centof our entire revenue to health will not be enough to solve the magnitude of the problem. However, we must recognise that the one per cent of the BHCPF is a step forward. If the federal government intervenes on the state’s behalf, I believe we should push the states to do more since it is their responsibility to enhance primary healthcare in the first place.

Your report used 20 indicators such as budgetary commitment, availability of human resources, and health legislation, amongst others, to rate state health systems. Let us talk about some of these indicators and what needs to change in order to drive improvement?

As you mentioned, the indicators broadly examine inputs, outcomes and processes. One issue with this evaluation is the lack of current data. There are also concerns about how recent the data used were. All these have been discussed extensively with different stakeholders.

One of the indicators considered is health workers density, which talks about the availability of workforce and training of community health workers; minimum service package, processes and output measures and annual operation plans; reporting and health product stock performance for things like drug availability; management of human resources at the primary health centers, as well as how you train and support them through the process. Others include the proportion of children between the ages of 12 to 23 months who received vaccination at any time before their 24th month and the experiences of users of some of these facilities in the state. 

Essentially, when we put these indicators together, we aimed to provide a comprehensive view of what a quality primary health service would look like. These indicators were not drawn randomly. They were based on information previously provided by primary healthcare facilities, but were not structured in a manner to provide a holistic view of service quality.

How involved has been your organisation in this fight for improved primary and we assess healthcare, and what more should we expect?

We have been involved since we arrived in Nigeria. We campaigned hard for the National Health Act, arguing that Nigeria needed to enable the legal framework to deliver quality healthcare. At ONE Campaign, our focus is to end extreme poverty, and we realised that health is one of the ways that can be done. So, we targeted primary healthcare improvement, in order to ensure that the poor and the vulnerable have access to quality healthcare at that level. We started demanding the setting up of the Basic Health Care Provision Fund in 2016. In essence, we have been involved, from getting the law passed to getting the fund operational. 

In terms of what to expect from us, we will complement the federal government’s accountability frameworks by offering an independent perspective on the state of primary healthcare in Nigeria. This is our way of encouraging all stakeholders in Nigeria to do more. We are going to be engaging the states one-on-one to discuss what may be done to enhance their health outcomes. A few state governors are also looking forward to discussing the findings of this report. We are looking at making this an annual report so that we can keep track of progress and pressure stakeholders to intensify efforts. This is our indirect way of supporting government’s efforts to continue to improve the quality of service delivered to the poor and vulnerable in the country through the BHCPF.

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